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Nephrostomy Treatment & Management

  • Author: Stefan H Hautmann, MD, PhD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Oct 22, 2015
 

Medical Therapy

An evaluation for nephrostomy can be conducted on an outpatient basis if the patient's medical condition permits. Inpatient studies and surgical treatment may be necessary in emergencies or in unstable patients.

  • Medications
    • Most patients should receive broad-spectrum parenteral antibiotics.
    • If drugs are administered, the authors recommend cephalosporin or a combination of penicillin and aminoglycoside prior to the procedure, depending on the patient's allergies.
    • In pediatric patients, adjust antibiotics for age and weight.
    • Drug contraindications include corresponding drug allergies and urinary tract infection in an elective setting, hepatic failure, and renal failure.
  • Pregnancy: During pregnancy, nephrostomy is limited to only selected individuals, such as those with symptomatic renal obstruction and an inability to access the kidney from the bladder.
  • Consultations
    • Nephrologist, for possible dialysis
    • Oncologist, for prognosis and survival of patients with oncologic causes for urinary tract obstruction
    • Surgeon and gynecologist for urinary tract obstruction due to disorders in their respective fields
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Surgical Therapy

Depending on the hospital situation, the nephrostomy can be placed under ultrasound guidance or direct fluoroscopy either by a urologist or a radiologist.

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Preoperative Details

See the list below:

  • No special diet is required if surgery is performed under local anesthesia.
  • The procedure can be performed under fluoroscopic or ultrasonographic guidance. A CT-guided nephrostomy or placement during open surgery is possible but only rarely used.
  • Perform the procedure in the operating room, the fluoroscopy suite, or the ultrasound room.
  • Use lead glasses, a thyroid shield, and a lead apron when overhead radiography is used. Limit fluoroscopy time and cone down the radiation field.
  • Several ultrasound transducers can be used (eg, 7.5-MHz transducers). Ultrasound has become the preferred guidance modality in the placement of a percutaneous nephrostomy. Opacifying the renal collecting system with intravenous or retrograde injection of iodinated contrast was once necessary to allow fluoroscopic visualization. The use of ultrasound reduces both the amount of radiation and the possible complications of intravenous administration. Furthermore, real-time multidimensional imaging reduces procedure time, allows visualization of adjacent structures, and reduces the possibility of iatrogenic trauma. Following placement of the nephrostomy needle, the procedure can be completed under ultrasonographic guidance; more commonly, the collecting system is opacified directly, and the procedure is completed under fluoroscopy.
  • Even if the kidney has limited hydronephrosis and still needs nephrostomy, ultrasonography can be used to identify the renal collecting system.
  • Proper selection of the appropriate calyx is vital in nephrostomy tube placement to allow access to various parts of the kidney. If the tube is placed too low, the ureter may be difficult to access; the ureter is easier to reach from an upper-pole calyx.
  • Failed access is occasionally a problem. When nephrostomy placement is not an emergency situation, wait a few hours (or even days) until the dilatation of the renal collecting system has increased to facilitate the puncturing of the collecting system.
  • The nephrostomy tract usually matures within a few weeks; therefore, the nephrostomy remains open for hours to days after the tube is removed following maturation. Whenever a tube is removed after a long period, place a pressure dressing to cover the skin and tract defect.
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Intraoperative Details

See the list below:

  • Always obtain adequate visualization of the calices.
  • Identify a posterior calyx for puncture that (1) provides access to the appropriate segment of the kidney for anticipated procedures and that (2) allows safe creation of a tract.
  • Puncture the collecting system of the kidney with a needle below the 11th rib and, preferably, below the 12th rib, when feasible.
  • Puncture the tip of a posterior calyx from a 20-30° posterior oblique approach to avoid major blood vessels (eg, renal vein, renal artery).
  • The nephrostomy can be placed through any posterior calyx within the kidney.
  • A lower-pole calyx is often selected for drainage because it is usually infracostal, thereby precluding a pneumothorax/hydrothorax complication, anatomy shown below.
    Positioning of nephrostomy tube into the lower polPositioning of nephrostomy tube into the lower pole of the kidney.
  • A supracostal puncture of the middle or upper portion of the kidney may be needed for stone or tumor removal.
  • Use 5 mL of lidocaine (1%) for local anesthesia.
  • Fluoroscopic guidance can be used for access, but some urologists and radiologists prefer ultrasonographic guidance (eg, with a 3-MHz or 5-MHz curvilinear transducer), especially until the nephrostomy needle passes into the collecting system.
  • After entering the collecting system, withdraw the obturator of the needle. If urine flow is present, use 3-5 mL of contrast to check for proper placement.
  • Advance a guidewire (eg, 0.035 in) into the collecting system.
  • Remove the needle with the guidewire in place.
  • Use a fascial incising needle or scalpel to cut the lumbodorsal fascia.
  • The tract can be dilated with a plastic fascial dilating catheter passed over the guidewire (6F, 8F, and 10F catheters). Further dilation of the tract may be necessary if a percutaneous nephrolithotomy is planned.[4, 5]
  • A nephrostomy catheter (8-14F) can be placed over the guidewire; affix it to the skin with a suture or plastic retainer.
    • The catheter size depends on the intended purpose of the nephrostomy. Simple urine drainage can be achieved with an 8F catheter. If the collecting system is punctured for further procedures in the kidney (eg, tumor or stone removal), a larger catheter must be used (14-22F).
    • Smaller tubes have some advantages and disadvantages compared with larger tubes. The smaller tubes cause less trauma and are easier to insert; however, they do not drain the kidney as well as the larger tubes and are less effective in compressing the tract. The larger tubes cause more trauma and are slightly more difficult to insert but offer better drainage of the kidney and compression of the tract.
    • As for catheter selection, Malecot-type catheters require a skin suture, while balloon catheters do not. Renal pelvis–dwelling catheters are more secure than nephro-stent–type tubes.[6]
  • The guidewire can be removed after the nephrostomy catheter has been checked fluoroscopically. If the tube leaks after placement, a larger tube may be used. However, most leakage resolves within a few hours. If the tube falls out, it can usually be replaced through the same tract (if the tract is matured). For freshly placed tubes, a new kidney puncture may be necessary.
  • Use a pigtail with a lock; most nephrostomy catheters have a locking mechanism to prevent displacement.
  • As indicated, send the aspirate from a kidney urine specimen for culture.
  • Bleeding during nephrostomy placement may be enough to terminate the procedure; however, clamping the tube for 30-40 minutes and administering intravenous diuretics stops most venous bleeding. For arterial bleeding, perform angiography and consider embolization of the bleeding vessel.
  • To preclude kinking, smoothly drape the tube as it exits the skin over a roll of gauze.
  • Connect the nephrostomy catheter to a urine bag that can be strapped to the leg.
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Postoperative Details

After nephrostomy tube placement, most patients have bloody urine for several hours; this bleeding usually resolves spontaneously. The nephrostomy tube can be irrigated gently with 5 mL of sodium chloride 0.9%. Clots can be removed from the nephrostomy catheter. Observe for fever if the urine appears cloudy. If the hematuria does not resolve spontaneously, troubleshoot the nephrostomy as follows:

  • If bleeding occurs from around the nephrostomy tube, an additional skin suture may resolve the bleeding.
  • If bleeding occurs inside the nephrostomy tube, check the bleeding time and CBC count; then, consider arteriography and possible segmental embolization of the kidney in the interventional radiology department.

Postobstructive diuresis can occur with polyuria (for management, refer to Medscape Reference articles Chronic Kidney Disease and Acute Renal Failure). Regularly check blood pressure, blood count, and urine until they become stable. Conditions vary according to individual circumstances.

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Follow-up

See the list below:

  • Further inpatient care may require testing and surgical intervention, which may include nephrolithotomy or reconstructive surgery.
  • Most patients can be discharged home the day of the procedure. Outpatient instructions focus on nephrostomy tube care (eg, change dressing daily, keep dressing dry and clean when showering, avoid submersion).
  • Patients should avoid strenuous activity and sports until the nephrostomy tube is removed.

Inpatient and/or outpatient medications

See the list below:

  • Prophylaxis with suppressive antibiotics is not recommended.[7, 8]
  • Medications include antibiotics (eg, cephalosporin in cases of urinary tract infections) until infection is treated.
  • Carefully monitor medication dose and adverse effects and treat infections only when symptomatic.
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Complications

Common complications

See the list below:

  • Perforation of the collecting system (< 30%) typically resolves within 48 hours of nephrostomy tube placement, provided that drainage of the collecting system is established (via nephrostomy tube or ureteral catheter).
  • Possible complications of the intercostal approach include pleural effusion, hydrothorax, and pneumothorax, possibly requiring chest tube placement (< 13%).
  • Acute bleeding requiring transfusion (< 5%): Bleeding through the nephrostomy tube may require clamping the tube for 30 minutes to 2 hours and subsequent irrigation of the tube with sodium chloride 0.9% after enforced diuresis.
  • Failed access (< 5%): Reattempt access after the dilatation of the collecting system has increased in the course of hours or days.

Rare complications

See the list below:

  • Periorgan injury, including bowel perforation, splenic injury, and liver injury (< 1%): Extraperitoneal colon injury and duodenal injury can be managed conservatively with stenting of the urinary system and using the percutaneous tube as an enterostomy tube for 48 hours. Afterward, remove the enterostomy.
  • Intraperitoneal injury that mandates open exploration (< 1%)
  • Infection leading to septicemia (< 1%)
  • Significant loss of functioning renal tissue (< 1%)
  • Delayed hemorrhage (< 0.5%): The authors recommend that patients in whom the nephrostomy is doubtful or difficult are kept overnight.
  • Emergency arterial embolization of the kidney (< 0.5%) with uncontrollable arterial bleeding: Clamping the nephrostomy tube for a few hours stops most venous bleeding.
  • Administration of antihistamines and steroids and use of nonionic or low-osmolar contrast media in cases of known allergic contrast reaction (< 0.2%)
  • Nephrectomy (< 0.2%)
  • Mortality (< 0.05%)

Patients with uncontrolled hypertension may develop perirenal hematoma or extensive renal hemorrhage. Use all efforts to control blood pressure.

A study found that as a patient's BMI increased, the likelihood of nephrostomy tube dislodgment increased in a directly proportionate fashion.[9]

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Future and Controversies

Medicolegal Pitfalls

See the list below:

  • Failure to obtain informed consent on the indications and complications
  • Removal of the nephrostomy tube
    • Fluoroscopic guidance may be necessary, especially to ensure proper drainage of urine through the ureter into the bladder prior to nephrostomy removal.
    • A thorough inspection of the catheter is necessary to ensure complete removal.
    • Retained fragments of a catheter predispose the patient to infection and calculi formation.

Acknowledgment

The authors thank E. Russel, MD, and H. Huson, MD, from the Department of Radiology and J. Posey, MD, from the Department of Urology of the University of Miami for their help.

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Contributor Information and Disclosures
Author

Stefan H Hautmann, MD, PhD Professor of Urology, Director, Department of Urology and Pediatric Urology, Luedenscheid Hospital, Academic Hospital of the University of Bonn, Germany

Disclosure: Nothing to disclose.

Coauthor(s)

Raymond J Leveillee, MD, FRCS(Glasg) Professor of Clinical Urology, Radiology and Biomedical Engineering, Department of Urology, University of Miami Miller School of Medicine; Chief, Division of Endourology/Laparoscopy and Minimally Invasive Surgery, Department of Urology, Jackson Memorial Hospital

Raymond J Leveillee, MD, FRCS(Glasg) is a member of the following medical societies: American Urological Association, Endourological Society, Sigma Xi, Society of Laparoendoscopic Surgeons

Disclosure: Received honoraria from ACMI/Gyrus for speaking and teaching; Received honoraria from Boston Scientific for speaking and teaching; Received honoraria from Applied Medical for speaking and teaching; Received honoraria from Intuitive Surgical for speaking and teaching; Received grant/research funds from Intio for other.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

References
  1. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. J Am Med Assoc. 1955 Mar 12. 157(11):891-4. [Medline].

  2. Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 1976. 10(3):257-9. [Medline].

  3. Alken P, Hutschenreiter G, Gunther R, et al. Percutaneous stone manipulation. J Urol. 1981 Apr. 125(4):463-6. [Medline].

  4. Parikh GP, Shah VR, Modi MP, Chauhan NC. The analgesic efficacy of peritubal infiltration of 0.25% bupivacaine in percutaneous nephrolithotomy - A prospective randomized study. J Anaesthesiol Clin Pharmacol. 2011 Oct. 27(4):481-4. [Medline]. [Full Text].

  5. Ozok HU, Sagnak L, Senturk AB, Karakoyunlu N, Topaloglu H, Ersoy H. A Comparison of Metal Telescopic Dilators and Amplatz Dilators for Nephrostomy Tract Dilation in Percutaneous Nephrolithotomy. J Endourol. 2011 Oct 14. [Medline].

  6. Li CC, Li JR, Huang LH, Hung SW, Yang CK, Wang SS, et al. Metallic stent in the treatment of ureteral obstruction: Experience of single institute. J Chin Med Assoc. 2011 Oct. 74(10):460-3. [Medline].

  7. Deshmukh S, Sternberg K, Hernandez N, Eisner BH. Compliance with American Urological Association Guidelines for Post-Percutaneous Nephrolithotomy Antibiotics Does Not Appear to Increase Rates of Infection. J Urol. 2015 Oct. 194 (4):992-6. [Medline].

  8. Viers BR, Cockerill PA, Mehta RA, Bergstralh EJ, Krambeck AE. Extended antimicrobial use in patients undergoing percutaneous nephrolithotomy and associated antibiotic related complications. J Urol. 2014 Dec. 192 (6):1667-72. [Medline].

  9. Bayne D, Taylor ER, Hampson L, Chi T, Stoller ML. Determinants of nephrostomy tube dislodgment after percutaneous nephrolithotomy. J Endourol. 2015 Mar. 29 (3):289-92. [Medline].

  10. Biyani CS, O'Connor JP, Browning AJ. Laparoscopic removal of retained nephrostomy tubing. J Urol. 2003 Sep. 170(3):916-7. [Medline].

  11. Bloom DA, Morgan RJ, Scardino PL. Thomas Hillier and percutaneous nephrostomy. Urology. 1989 Apr. 33(4):346-50. [Medline].

  12. Carson CC, Little N. The absolute and relative contraindications to ESWL. Problems in Urology. Philadelphia, Pa: JB Lippincott Co; 1987. Vol 1: 580.

  13. Clayman RV, Kavoussi LR. Endosurgical techniques for noncalculous disease. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1992. 2235-45.

  14. Coleman CC, Kimura Y, Reddy P. Complications of nephrostolithotomy. Sem Intervent Radiol. 1984. 1:24.

  15. Grasso M, Loisides P, Beaghler M, et al. The case for primary endoscopic management of upper urinary tract calculi: I. A critical review of 121 extracorporeal shock-wave lithotripsy failures. Urology. 1995 Mar. 45(3):363-71. [Medline].

  16. Grasso MG, Taylor F. Techniques for percutaneous renal access. Sosa RE, Albala DM, eds. Textbook of Endourology. Philadelphia, Pa: WB Saunders Co; 1996.

  17. Kaskarelis IS, Papadaki MG, Malliaraki NE, et al. Complications of percutaneous nephrostomy, percutaneous insertion of ureteral endoprosthesis, and replacement procedures. Cardiovasc Intervent Radiol. 2001 Jul-Aug. 24(4):224-8. [Medline].

  18. Kavanagh DO, Fanning N, Heffernan E, et al. Management of gestational nephrolithiasis in the presence of a bicornuate uterus and pelvic kidney. Int J Urol. 2005 Feb. 12(2):211-3. [Medline].

  19. Kukreja R, Desai M, Patel S, et al. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol. 2004 Oct. 18(8):715-22. [Medline].

  20. Lam HS, Lingeman JE, Mosbaugh PG, et al. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy. J Urol. 1992 Sep. 148(3 Pt 2):1058-62. [Medline].

  21. LeRoy AJ, Williams HJ Jr, Bender CE, et al. Colon perforation following percutaneous nephrostomy and renal calculus removal. Radiology. 1985 Apr. 155(1):83-5. [Medline].

  22. Little B, Ho KJ, Gawley S, et al. Use of nephrostomy tubes in ureteric obstruction from incurable malignancy. Int J Clin Pract. 2003 Apr. 57(3):180-1. [Medline].

  23. Mariappan P, Smith G, Bariol SV, et al. Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study. J Urol. 2005 May. 173(5):1610-4. [Medline].

  24. Motola JA, Smith AD. Therapeutic options for the management of upper tract calculi. Urol Clin North Am. 1990 Feb. 17(1):191-206. [Medline].

  25. Picus D, Weyman PJ, Clayman RV, et al. Intercostal-space nephrostomy for percutaneous stone removal. AJR Am J Roentgenol. 1986 Aug. 147(2):393-7. [Medline].

  26. Segura JW. Percutaneous management. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1992. 2183-94.

  27. Segura JW, Preminger GM, Assimos DG, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol. 1994 Jun. 151(6):1648-51. [Medline].

  28. Smith AD. Management of iatrogenic ureteral strictures after urological procedures. J Urol. 1988 Dec. 140(6):1372-4. [Medline].

  29. Strohmaier WL, Giese A. Ex vivo training model for percutaneous renal surgery. Urol Res. 2005 Jun. 33(3):191-3. [Medline].

  30. Tanaka T, Yanase M, Takatsuka K. Clinical course in patients with percutaneous nephrostomy for hydronephrosis associated with advanced cancer. Hinyokika Kiyo. 2004 Jul. 50(7):457-62. [Medline].

  31. Whitaker RH. An evaluation of 170 diagnostic pressure flow studies of the upper urinary tract. J Urol. 1979 May. 121(5):602-4. [Medline].

  32. Zagoria RJ, Dyer RB. Do's and don't's of percutaneous nephrostomy. Acad Radiol. 1999 Jun. 6(6):370-7. [Medline].

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Renal anatomy.
Positioning of nephrostomy tube into the lower pole of the kidney.
Outside appearance of a nephrostomy tube from the flank after stone removal.
CT scan of bilateral hydronephrotic kidneys without intravenous contrast medium.
CT scan with dilated right ureter without intravenous contrast medium.
 
 
 
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